JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Adolescent Asthma Study Interest Form
Please fill in the following information to learn more about this study and to learn if your adolescent might be eligible to join. Pharmaceutical Research & Consulting is a clinical research office in Dallas, TX, and will only use the information you provide to share details about the study. We will never share your information. To learn more about us, please view our website at
Dallas Allergy & Asthma Center (daac-prc.com)
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Zip Code
Your answer
Please indicate which of the following best describes the adolescent with asthma interested in learning about this study:
At least 12, but less than 18 years of age.
*
Yes
No
Diagnosed with asthma at least 12 months ago
*
Yes
No
Currently using an inhaled corticosteroid medication (on its own, or in combination with another asthma medication.
*
Yes
No
Over the last 12 months, has had at least 1 but no more than 3 severe asthma episodes that required additional steroid medication, an emergency department visit, or a hospital stay.
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report